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What Can Be Done to Enhance Efficiency and Promote Value?

What Factors Affect Costs of Health Care?

There is widespread agreement among policymakers, providers, and the public that health care expenditures must be curtailed. But stakeholders disagree on the best way to bring rapidly escalating costs under control while maintaining quality and promoting value. Our policy analysis for state and federal agencies and the health care industry provides timely and reliable information on the effectiveness of health care investments and an accurate analysis of what needs remain unmet. Related publications include:

"How Does Insurance Coverage Improve Health Outcomes?" Reforming Health Care # 1. (April 2010). This brief synthesizes the compelling research evidence linking health insurance to good health outcomes.
"Experience from 2006: State Health Care Expenditures." (Baltimore: Maryland Health Care Commission, January 2008). Tracks trends in state health care expenditures to inform policy deliberations among health care experts, professionals, executives, and legislators.
“State Health Care Expenditures: Experience from 2005” (Baltimore: Maryland Health Care Commission, February 2007). Tracks trends in state health care expenditures to inform policy deliberations among health care experts, professionals, executives, and legislators.
"Geographic Variation in Medicare Per Capita Spending: Should Policymakers Be Concerned?" Policy Brief No. 6. (July 2004). Examines the substantial variations in Medicare spending geographically and the underlying factors.

What Methods Work for Measuring and Reporting the Quality of Health Care?

The quality of health care is an elusive concept, yet it is difficult to design systems to improve quality without practical means of measuring and reporting on it. Mathematica’s quality-of-care research investigates measures that can be developed from available data and better measures that could be generated from new systems. This work has the potential to help policymakers find ways to improve care delivery and avoid medical mistakes that contribute to hundreds of thousands of preventable illnesses and deaths and cost billions of dollars annually. Related publications include:

"The Business Case for Accurate Data on Quality and Savings in Medical Home Programs."
Presentation. National Medical Home Summit (March 2010) 
"Health Plans' Use of Physician Resource Use and Quality Measures"
(October 2007). Investigates use of physician-level measures in the private sector in four health markets around the country: Austin, Boston, Cleveland, and Seattle.
"Hospital Response to Public Reporting of Quality Indicators." (Health Care Financing Review, spring 2007). Reviews a 2005 national survey of senior hospital executives and notes that Hospital Compare and other public reports on hospital quality measures have helped to focus hospital leadership attention on quality matters.
"Improving Health Care Quality Reporting: Lessons from the California HealthCare Foundation" (January 2007). Looks at the role that regional, state, and local foundations can play in the development of accurate and useful quality measurement and reporting systems and describes results from a California-based effort.
"Using Quality Information for Health Care Decisions and Quality Improvement" Literature Review (May 2005). Reviews research on incentives for and barriers to quality reporting, and takes stock of what CAHPS has accomplished to date.

How Effective Are Innovative Ways of Delivering Health Care?

Mathematica's rigorous research into disease management and care management initiatives indicates that these efforts have had only limited success. We are now turning to how to build on these few successes to find better systems of care. Related publications include:

"Medical Homes: Will They Improve Primary Care?" Reforming Health Care Issue Brief # 6 (June 2010). This brief looks at federal and state efforts to establish medical homes and notes considerations for policymakers seeking to improve access to services and the quality of care. 
"Encouraging Appropriate Use of Preventive Health Services." Reforming Health Care Issue Brief # 2 (May 2010). This brief summarizes evidence on the benefits and cost-effectiveness of preventive health services, noting that health reform brings significant new opportunities to improve access to preventive care.
"Disease Management: Does It Work?" Reforming Health Care Issue Brief # 4 (May 2010). This brief looks at the research evidence on the effectiveness of disease management programs and the role of disease management in health care reform.
"Quality's New Frontier: Reducing Hospitalizations and Improving Transitions in Long-Term Care." Trends in Health Care Quality #7 (March 2010). This brief reviews recent efforts to measure and reduce potentially avoidable hospitalization and improve care transitions for individuals who use long-term care, including residents of nursing homes and people in home- and community-based service
settings.
"Using Qualitative and Quantitative Methods to Evaluate Small-Scale Disease Management Pilot Programs."Population Health Management (February 2009). This paper describes a multi-method approach for evaluating 10 small interventions that participated in the Medicaid Value Program, which sought to improve quality of care for Medicaid beneficiaries with multiple chronic conditions.
"Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries: 15 Randomized Trials." Journal of the American Medical Association (February 2009). Presents findings from the third report to Congress on the Medicare Coordinated Care Demonstration.
"Enhanced Primary Care Case Management Programs in Medicaid: Issues and Options for States." (September 2009). This report examines how five states—Oklahoma, North Carolina, Pennsylvania, Indiana, and Arkansas—have enhanced their Medicaid primary care case management programs to provide more intensive care management and care coordination for high-need beneficiaries, improve financial and performance incentives for primary care providers, and increase use of performance and quality measures.
"Strategies for Reining in Medicare Spending Through Delivery System Reforms: Assessing the Evidence and Opportunities" (Menlo Park, CA: The Henry J. Kaiser Family Foundation, September 2009). Reviews proposed reforms to strengthen Medicare’s long-term fiscal outlook.
"The Promise of Care Coordination: Models that Decrease Hospitalizations and Improve Outcomes for Medicare Beneficiaries with Chronic Illnesses" (Las Vegas, NV: American Society on Aging and the New York Academy of Medicine National Forum on Care Coordination, March 2009). Synthesizes evidence on cost-effective interventions and their components, identifies issues that must be resolved for ongoing research, and presents recommendations for care coordination policies in health care reform that can be supported by available evidence.
"Matching Patients to Medical Homes: Ensuring Patient and Physician Choice" Policy Perspective: Insights into Health Policy Issues, No. 1 (December 2008). Identifies key operational issues facing medical home initiatives.
"15-Site Randomized Trial of Coordinated Care in Medicare Fee-for-Service" (Health Care Financing Review, fall 2008). Finds mixed success for Medicare fee-for-service beneficiaries who had chronic illnesses and volunteered to participate in one of 15 care coordination programs.
"Impacts of a Disease Management Program for Dually Eligible Beneficiaries" (Health Care Financing Review, fall 2008). Examines interim impacts of a disease management demonstration for Medicare fee-for-service beneficiaries also enrolled in Medicaid (dual eligibles). Findings during the first 18 months show no impacts on hospital or emergency room use, Medicare expenditures, quality of care, or prescription drug use.
"Report to Congress on the Evaluation of Medicare Disease Management Programs" (February 2008). There were no impacts on key outcomes of Medicare Part A and B expenditures and service use for this demonstration program for fee-for-service Medicare beneficiaries with advanced congestive heart failure, diabetes, or coronary artery disease.
"Third Report to Congress on the Evaluation of the Medicare Coordinated Care Demonstration" (January 2008). Evaluates whether disease management, in conjunction with comprehensive prescription drug benefits, improves health outcomes and reduces costs.

What New Medicare Developments Can Foster Health Care Reform?

More resources are needed to sustain the Medicare program as baby boomers retire and the elderly and disabled population expands. Mathematica is at the forefront of studying how Medicare is changing and meeting the needs of beneficiaries. Related publications include:

"Promising Models of Care Coordination in Medicare: Lessons for Medicaid Beneficiaries with Chronic Illnesses."
National Academy for State Health Policy Annual Conference (October 2009)
"Strategies for Reining in Medicare Spending Through Delivery System Reforms: Assessing the Evidence and Opportunities" (Menlo Park, CA: The Henry J. Kaiser Family Foundation, September 2009). Reviews proposed reforms to strengthen Medicare’s long-term fiscal outlook.
"Disabled Americans' Long Wait for Health Coverage"
(December 2008). Web interview with Gina Livermore discusses our study looking at the impact of Medicare's waiting period on people with disabilities, and the struggles they encounter as they navigate the maze of SSDI and Medicare.
"Medicare's Private Plans: A Report Card on Medicare Advantage" (November 2008). Notes that costs and complexity are up, while care has not improved.
“Health Benefits for the Uninsured: Design and Early Implementation of the Accelerated Benefits Demonstration” (September 2008). Describes findings from the initial phase of a demonstration project designed to test whether providing earlier access to health benefits for beneficiaries with disabilities reduces long-term dependence on cash benefits.
"Medicare Advantage in 2008" (June 2008). Tracks trends in firm participation and market share, as well as beneficiary choice.
"Monitoring Medicare+Choice: What Have We Learned? Findings and Operational Lessons for Medicare Advantage" (August 2004). Although sponsors originally hoped Medicare+Choice would lead to a greater role for private plans in Medicare, this report notes that the program is widely viewed as a failure, with plans leaving and beneficiaries having fewer, less attractive choices when the program ended in 2003 than they did when it began.
"Elimination of Medicare's Waiting Period for Seriously Disabled Adults: Impact on Coverage and Costs" (July 2003). Notes that dropping the waiting period would save states money.

Do Consumer Education, Shared Decision Making, and Other Strategies Help Reform Organization of Care?

There is growing interest in ensuring that doctors and patients work together as partners in making health care decisions and contribute equally to the process of determining the course of care. The goal is to ensure that information on health care choices and preferences is shared, to improve satisfaction and outcomes of treatment, and to promote value. We have looked at these issues for populations across the lifespan, from children to elderly adults. Related publications include:

"Engaging Consumers: What Can Be Learned from Public Health Consumer Education Programs?"
(March 2008). Explores what can be learned from public health campaigns about strategies for engaging consumers and influencing their behavior.
"Cash and Counseling: Improving the Lives of Medicaid Beneficiaries Who Need Personal Care or Home- and Community-Based Services" (August 2007). Summarizes findings from five years of research on how each of three demonstration states implemented a Cash and Counseling program, and on how the programs have affected consumers who participated, consumers’ paid and unpaid caregivers, and costs to Medicaid.
"Testing Consumers' Comprehension of Quality Measures Using Alternative Reporting Formats" (Health Care Financing Review, spring 2007). Reports on efforts to develop and test seven alternative reporting templates to improve comprehension.
"Estimating the Proportion of Health-Related Websites Disclosing Information that Can Be Used to Assess Their Quality" (May 2006). Details efforts to develop, test, and implement a methodology for estimating the proportion of health websites that disclose information consistent with the identified criteria.

What Provider Payment and Financial Incentives Are Most Effective?

As policymakers and health plans search for ways to align payment with quality, Mathematica has been examining ways to adjust payment mechanisms and incentives. We have conducted case studies and quick-turnaround discussions with providers and health plans to understand their preferences and offer timely information about pay for performance in public and private programs. We have also supported efforts to help consumers and purchasers review information about the quality of care provided by various health plans and make better choices. Related publications include:

"Financial Incentives for Health Care Providers and Consumers" Reforming Health Care Issue Brief # 5 (May 2010). This brief looks at evidence on the impacts of these financial incentives and draws lessons for policymakers.
"Using Physician Payment Reform to Enhance Health System Performance" (December 2008). Explores what is known about using physician payment to improve health system performance and promote value, suggesting that future priorities move beyond pay for performance of individual services and reward physicians for influencing totality of a patient’s care across all providers and settings.
"Making Pay-for-Performance Work in Medicaid” Health Affairs (June 2007). Examines five Medicaid-focused health plans that implemented new financial incentives for physicians to improve the timeliness of well-baby care.
"Pay for Performance: Are Hospitals Ready and Willing?" (November 2006). Examines hospital public reporting of quality information.
"Translating Research to Action: Improving Physician Access in Public Insurance" Journal of Ambulatory Care Management (January-March 2006). Synthesizes research and provides a framework that policymakers can use to identify and measure barriers to physician access in public insurance, determining where and why problems exist and how to intervene.
"Effects of Selected Cost-Containment Efforts: 1971-1993" Health Care Financing Review (1993). This article reviews the literature on four types of supply-side price controls for health care, and although it looks at an older time period, the same issues persist today.